The U.S. & Gavi, the Vaccine Alliance

Overview

Gavi, the Vaccine Alliance (Gavi) is an independent, public-private partnership and multilateral funding mechanism that aims to “save children’s lives and protect people’s health by increasing access to immunization in poor countries”.1 Created in 1999, Gavi was formally launched in January 2000. Through September 2014, the partnership had received over $10 billion in financing.2 Gavi receives contributions through direct donations from public and private donors, through matching funds programs, and through donor investments in two innovative financing mechanisms – the International Finance Facility-Immunisation (IFFIm) and the Advance Market Commitment (AMC).3 In turn, Gavi has committed over $8.7 billion in support of immunization programs in 76 low- and middle-income countries (as of June 2014).4

The U.S. government has supported Gavi since its creation, including through direct financial contributions, participation in governance, and technical assistance. The U.S. has been one of Gavi’s top government donors, as measured by direct contributions, having provided approximately 10% of all contributions received by the Alliance from 2000 through September 2014 (Figure 1).

Gavi has been cited by the Obama Administration as an important multilateral partner, and U.S. financial support to Gavi has grown over time.5 Notably, the U.S. government has made two multi-year pledges of support for Gavi over the last several years. In June 2011, the U.S. made its first multi-year commitment to Gavi , pledging $450 million over three years (FY2012-FY2014), a pledge which was met.6,7 In January 2015, at the time of the most recent Gavi donor pledging conference, the U.S. announced another multi-year funding pledge totaling $1 billion over four years (FY2015-FY2018).8

Gavi’s financing needs have grown over time, and are expected to continue to grow due to increasing country demand, the growth in the number of vaccines supported through Gavi, and potential addition of still other vaccines to the Gavi portfolio.

Organizational Structure

Gavi, initially created as a partnership of donors, recipient governments, and other organizations, reorganized as a Swiss Foundation with international institution status in 2009. It maintains two offices, in Geneva and in Washington D.C., but does not have program staff in-country. A team of Country Responsible Officers based in Geneva oversees the partnership at country level and works closely with country governments, partner organizations (particularly UNICEF, WHO, and the World Bank), and civil society organizations to assist countries improve national immunization programs. Gavi is governed by a broad set of public and private stakeholders, with the U.S. government involved in several of the Alliance’s core governance components.

Board

Gavi’s 28-member board sets the funding policies and strategic direction for the partnership. Its membership is composed as follows9:

4 institutional seats, one each for UNICEF, WHO, the World Bank, and the Gates foundation;

5 seats for industrialized country governments (a U.S. representative, from USAID, is currently an alternate in the rotating seat representing the U.S./Australia/Republic of Korea/Japan constituency),

5 seats for developing country governments,

1 seat for the Research & Technical Health Institute constituency,

1 seat for the industrialized country vaccine industry constituency,

1 seat for the developing country vaccine industry constituency,

1 seat for the civil society organizations constituency;

9 unaffiliated seats for private, independent individuals with expertise in critical areas such as investment, auditing, and fundraising;

1 non-voting seat for the CEO of the Gavi Alliance.

The U.S. government also currently provides a representative on Gavi Alliance’s Program and Policy Committee and its constituency is represented on the Executive Committee.

Goals, Financing, & Results

Goals.Gavi’s current five-year strategy (for the 2011-2015 period) includes four core goals: 1) accelerate the uptake of new and underused vaccines; 2) help build health systems and capacity to deliver immunizations; 3) improve the predictability and sustainability of global and domestic financing for immunization; and 4) impact the vaccine market by lowering prices and increasing production.10 Gavi’s board has approved a 2016-2020 strategic plan also with four goals, though with a slightly different emphasis. The four goals for the 2016-2020 strategy are: 1) Accelerate equitable uptake and coverage of vaccines; 2) Increase effectiveness and efficiency of immunization delivery as an integrated part of strengthened health systems; 3) Improve sustainability of national immunization programs; and 4) Shape markets for vaccines and other immunization products.11

Financing.In addition toreceiving the more traditional direct financial contributions from public and private donors, Gavi programs have also been supported through unique innovative financing mechanisms such as IFFIm and the AMC. IFFIm uses long-term donor commitments to back the issuance of Vaccine Bonds in the capital markets, which essentially “front-loads” donor financing.12 Since it debuted in 2006, IFFIm has become an important source of funding for the Alliance (Figure 1). The AMC, which began operating in 2010, is an advance market commitment “pull mechanism” with manufacturers that aims to accelerate access to pneumococcal vaccine in low-income countries.13
To ensure stability and predictability in the Alliance’s financing going into the 2016-2020 period, Gavi and its partners held a second replenishment meeting in January 2015 (the first occurred in 2011), which brought together donors, implementing countries, vaccine manufacturers, and others to mobilize support and make pledges and commitments to Gavi.14 During the replenishment meeting, donors pledged over $7.5 billion in additional financing for Gavi.15

Eligibility and Country Support. Countries with a Gross National Income (GNI) per-capita below or equal to $1,580 that meet benchmarks for commitment to vaccine delivery and, depending on the vaccine, burden of disease, are eligible to apply for Gavi support.16 Gavi provides the great majority of its support to countries in the form of “new and underused” vaccines (and accompanying injection equipment), with smaller amounts of assistance provided through cash grants meant to support countries’ vaccine delivery systems, and broader health systems strengthening and civil society (Figure 2). Recipient governments are expected to share responsibility for funding their national immunization efforts through “co-financing” requirements, determined according to country income level. As countries develop economically, a greater domestic share of financing for their immunization programs is expected.17 When countries’ incomes rise above the threshold, they “graduate” from Gavi eligibility. Some countries have already graduated, while approximately 20 others, including countries such as Indonesia, Bolivia, and Mongolia, are due to graduate in the coming years.18,19

Results. According to Gavi, its activities since 2000 have led to half a billion children being immunized, preventing more than an estimated 7 million child deaths.21 The WHO has also estimated that Gavi support has helped to reverse previously stagnating or declining coverage rates of childhood vaccinations in low-income countries, increasing average vaccine coverage from 66% to 79% over its first decade.22 Gavi reports that the additional $7.5 billion for the 2016-2020 period pledged by donors at the January 2015 pledging conference will result in a further 300 million children being vaccinated and prevent between 5 and 6 million deaths.15

U.S. Engagement with Gavi

The U.S. has supported Gavi since its creation. President Clinton made the initial U.S. pledge to the newly formed partnership in 2000, and the U.S. donation of $47m in 2001 was the first public funding received by Gavi.23,24 Since then, U.S. support has increased. In 2011 the Obama administration made the first ever multi-year funding commitment to Gavi, pledging $450m over 3 years (FY2012-FY2014), which has been met. In FY2015, the U.S. contribution to Gavi reached its highest level ever, $200m (Figure 3)25. In January 2015, the U.S. committed to increase its support for Gavi even more, pledging $1 billion over 4 years (FY2015-FY2018), or an average of $250 million a year; this commitment is subject to Congressional appropriations of these funds.26 Gavi funds have been appropriated as part of the Global Health and Child Survival (GHCS) account at USAID, within the Maternal and Child Health (MCH) budget line.

While the U.S. provides direct contributions to Gavi, it does not support either of the innovative financing mechanisms, the IFFIm and the AMC, that other donors have utilized to finance Gavi programs and which together comprise a significant source of funding for the Alliance. This is due to multiple factors, particularly the inherent difficulties for the U.S. to make spending commitments (beyond non-binding pledges) for multi-year funding due to U.S. budgeting and appropriations processes, which are annually-focused.27

In addition to its role as a donor and in Gavi’s governance, the U.S. also provides Gavi with technical support and expertise in the design, implementation, and evaluation of its programs in the field through partnerships with several agencies. For example, Gavi’s accelerated introduction programs for the pneumococcal and rotavirus vaccines have been conducted with technical support from CDC and USAID, along with other partners.

Figure 3: U.S. Contributions to Gavi, the Vaccine Alliance 2001-2015

Support of Gavi has been only one component of a broader set of activities the government is engaged in to increase access to immunizations in developing countries. In addition to providing funding for immunizations through the multilateral Gavi mechanism, the U.S. provides bilateral immunization support through USAID, CDC, and other agencies.28 The two types of assistance are intended to be complementary, with Gavi supporting the introduction of new and underused vaccines into routine immunization, and bilateral aid supporting immunization system improvements to help deliver Gavi-financed and other vaccines to populations in need.29,30 Many of the countries in which the U.S. carries out its global health programs also receive support from Gavi.

Looking Ahead

Gavi has been recognized as an important multilateral partner for the U.S. government in efforts to introduce new vaccines, support immunization programs, and improve health in developing countries, especially child health. Going forward, some key policy issues facing the Alliance and the U.S. as a key Gavi partner include: ensuring that donor support will meet its future financing needs, which are expected to grow as current programs are expanded and new vaccines (such as a potential new malaria vaccine) are added to the Gavi portfolio; the expected graduation of many countries from Gavi eligibility even as those countries are home to under-immunized populations, creating the need for greater country co-financing and/or more flexibility for Gavi in its financing approaches as a result; how much future U.S. support for Gavi will be made available by Congress, given potential fiscal constraints in the U.S. federal budget; how to make the greatest progress toward goals and objectives for global immunization through the most effective combination of support to Gavi and to U.S. bilateral programs; and how to leverage U.S. expertise for Gavi through technical assistance and governance engagement with the Alliance.